effects of dexmeditomidine infusion for fess under local anaesthesia coauthors prof&head :...
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EFFECTS OF DEXMEDITOMIDINE INFUSION FOR FESS UNDER
LOCAL ANAESTHESIA
COAUTHORS
PROF&HEAD : Dr.I.CHANDRA SEKARAN. MD.,DA.PROF. Dr.S.C.GANESH PRABHU. MD.,DA.ASST.PROF. Dr.SHANMUGA SUNDARAM, MD
AUTHOR : Dr. K.M.LAKSHMANA RAJAN (PG)
INSTITUTE OF ANAESTHESILOGY,MMC,MADURAI
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INTRODUCTION
• FESS - GA / LA
• Under LA – Adequate sedation,analgesia, with nil or minimal side effects
• Patient’s comfort
• Surgeon’s comfort
• Need anesthesiologist or anaesthetic agent
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AIM
• To assess the hemodynamic effects, sedation, and duration of analgesia of
DEXMEDETOMIDINE INFUSION
in patients undergoing FUNCTIONAL ENDOSCOPIC SINUS SURGERY
under local anaethesia
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STUDY DESIGN• Ethical committee approval & consent from patients • Prospective, placebo-controlled, randomised double blind
study• INCLUSION CRITERIA:
- 40 ASA I, II Patients undergoing FESS under local anaesthesia
-Age: 18-60Yrs• EXCLUSION CRITERIA: -multiple sinus disease-prolonged surgery
-heart block ,hypotension-hypersensitivity to study drugs
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METHODOLOGY
• Assigned in 2 groups D & S(20 EACH)
• Baseline hemodynamic parameters recorded
• premedication(45 mins prior) -Inj.pethidine 50mg
-glycopyrrolate 0.2mg IM
• Nasal cavity packed with 4%Lignocaine & Adrenaline
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• GROUP D- 15 mins prior to surgery IV bolus of dexmedetomidine
1μg/Kg infusion for 10 min
• surgery will be commenced with Infiltration of nasal mucosa - 2%lignocaine & adrenaline
• 0.7μg/kg/hr infusion as maintenance
• Maintenance infusion stopped 15 mins before the end of surgery
• Group S- NS
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INTRAOPERATIVE MONITORING
• Done by theatre anesthetist– BP-Systolic & diastolic – PR every 10 min– SpO2– Sedation score- ramsay sedation scale– Grading of bleeding- bleeding graded by same
surgeon
Brady cardia(HR < 50/min) ,severe hypotension MAP<60mmhg-study drug will be stopped and treated accordingly
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POST OP MONITORING
• Duration of analgesia-time to reach VAS score >4• Inj .Diclofenac 75 mg im given
• No of episodes of nausea ,vomiting – noted & treated
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SEDATION SCORE
1- Patient anxious and agitated or restless
2- Patient co-operative, oriented, and tranquil
3- Patient responds to commands only
4- Patient exhibits brisk response to light glabellar tap or loud auditory stimulus
5- Patient exhibits a sluggish response to light glabellar tap or loud auditory stimulus
6- Patient exhibits no response
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GRADING OF BLEEDING
Qualitative grading
• 1- Cadaveric condition; minimal suction
• 2- Minimal bleeding; infrequent suction
• 3- Brisk bleeding; frequent suction.
• 4- Bleeding covers field after removal of suction.
• 5- Uncontrolled bleeding ; Bleeding out of nose on removal of suction.
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ANALYSIS
• Demographic datas
• Hemodynamic parameters-HR,MAP,SPO2
• Sedation score
• Bleeding grade
• Nausea and vomiting
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STATISTICAL ANALYSIS
• CHI-SQUARE TEST
• MANN-WHITNEY U TEST
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DEMOGRAPHIC DATAS GROUP
AGE(MEDIAN±2SD)
SEX(M/F)
WEIGHT(MEDIAN±2SD)
D 26.1±6.766014 10/1054.4±3.647638
S 26.1±5.766014 11/956.15±5.294237
P(>0.05)INSIGNIFICANT
0.76 .755 0.376
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SEX WEIGHT
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PRE OP HR & MAPGROUP
PRE OP HRMEDIAN ±2SD
PRE OP MAPMEDIAN ±2SD
D 81.3 ±3.2298.46±7.25
S 80.2±3.12 97.54±6.89
P(>0.05)INSIGNIFICANT
0.563 0.989
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PRE OP HR PRE OP MAP
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0-15 MINS
GROUPHR 0-15MINS (Median ±2SD)
MAP 0-15MINS(Median ±2SD)
D 100.8±3.233 86.8±1.22
S 105.4±3.766 96. 1±1.32
P(<0.05)0.091
INSIGNIFICANT0.000
SIGNIFICANT
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0-15 MINSHR MAP
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0-15 MINS
HR MAP
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15-75 MINS
GROUP HR
(Median ±2SD)MAP
(Median±2SD)
D 68.56±2.43 68.47±1.98
S 96.67±2.88 97.2±2.01
P(<0.05)SIGNIFICANT
O.OOO O.OOO
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15-75 MINS
HR MAP
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15-75 MINS
HR MAP
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SPO2
GROUPMEDIAN
±2SDP(>0.05)
SPO2 D 98.44±1.56
SPO2S 98.43±1.770.910
INSIGNIFICANT
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RAMSAY SEDATION SCORE
GROUPMedian ±
2SDP(<0.05)
D 3.094±0.1155
SIGNIFICANT
S 2.111±0.1612 0.000
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SEDATION
GROUP D GROUP S
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BLEEDING GRADEGROUP Median ±2SD P(<0.05)
D 1.75±0.444SIGNIFICA
NT
S 3.25±0.444 0.000
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DURATION OF ANALGESIA
GROUP Median ±2SD P(<0.05)
D 233.25±20.408
S 97.25±17.731 0.000
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PONV
GROUP Mean RankP(<0.05)
D 17.425INSIGNIFI
CANT
S 23.575 0.069
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MECHANISM FOR SEDATION
• Hyper polarization of locus ceruleus neurons
– 2A-Adrenoreceptor subtype
– Activation of K+ channels
– Inhibition of Ca++ channels
– Inhibition of adenylyl cyclase
Firing rate of locus caeruleus neurons
Activity in ascending noradrenergic pathway
• ACTIVATES NATURAL SLEEP PATHWAYS
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ANALGESIC EFFECT
Disinhibit A5/A7 Disinhibit A5/A7 noradrenergic pathwaysnoradrenergic pathways
Descending inhibitory Descending inhibitory pathwayspathways
Decrease emotive Decrease emotive aspectsaspects
Subcortical + cortexSubcortical + cortex
Inhibit firingInhibit firingSecond order neuronsSecond order neurons
Inhibit release of Inhibit release of SP and glutamateSP and glutamate
Primary afferent Primary afferent neuronsneurons
Inhibit sympathetic- Inhibit sympathetic- mediated painmediated pain
Peripheral nociceptorsPeripheral nociceptors
2 2 AgonistsAgonists
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HEMODYNAMIC EFFECTS
• Initially acts on peripheral alpha 2 receptors-increase in BP/HR-15 mins
• Postsynaptic activation of α2 adrenoceptors in the central nervous system (CNS)
• Inhibits sympathetic activity and
• Decrease blood pressure and heart rate
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SUMMARY
• RDB study in 40 pts ASA I & II for FESS under LA
• Dexmedetomidine and saline
• Hemodynamics ,sedation,bleeding grade,duration of analgesia,PONV
• Reduction in HR ,MAP in group D than group S
• Slow rising high ramsay sedation score in group D
• Better surgical field with low bleeding grade in group D than S
• Prolonged duration of pain relief (3.30 hrs to 4 hrs ) in group D than group S(0.40-1.40 hrs)
• No respiratory depression in both the groups
• Better patient and surgeon’s comfort in group D
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CONCLUSION
DEXMEDETOMIDINE
Good Sedative , Analgesic & Can Be Used As a Hypotensive Anesthetic To Control
Bleeding With Out Respiratory Depression For
FESS UNDER LOCAL ANAESTHESIA
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REFERENCES
• EUROPEAN JOURNAL OF ANESTHESIOLOGY JAN 2008
Goksu, S.; Arik, H.; Demiryurek, S.; Mumbuc, S.; Oner, U.; Demiryurek, A. T
• J CLIN ANAESTHESIA 2008 SEP
• Effectiveness of dexmedetomidine in reducing bleeding during septoplasty and tympanoplasty operations
• Ayouglu H ,Yapakci O,Ugur MB,Uzun L,Altunkaya H,Ozer Y,Uyanik R.
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Thank You!